|First Name: _____________________||Last Name: ______________________|
|Affliation: ______________________||Email: __________________________|
|Street Address:||Telephone: _______________________|
|___________________________||Name on Badge: __________________|
|City: ___________________________||State/Provence: ____________________|
|Zip/Postal Code: ____________||Country: __________|
|Dietary Restrictions: Vegetarian||Other (specify): ________________
|Credit Card (please check one):||
|Credit card number:||____________________________________|
|Name as it appears on the credit card:||____________________________________|
|Total Charges Authorized:||$190.00||($220.00 if received after Sept 25)|
|Do you need a hard copy receipt?|| [ ] YES
[ ] NO
Please note that by signing above, your credit card will be charged $190.00 (or $220.00 if received after September 25th).
For further information please contact the workshop chairs.